Original Research
Donna Dowling, PhD, RN ❍ Section Editor
Parental Experience Learning to Feed Their Preterm Infants Emily E. Stevens, PhD, RN, WHNP, FNP-BC; Elizabeth Gazza, PhD, RN, LCCE, FACCE; Rita Pickler, PhD, RN, PNP-BC, FAAN
ABSTRACT PURPOSE: Although extensive research has been conducted on preterm infant oral feeding, few investigations have examined parents’ experiences learning to feed orally their preterm infant while in the neonatal intensive care unit (NICU). As such, the aim of this study was to explore parental learning experiences to gain a better understanding of the process parents use in learning to feed their preterm infant. SUBJECTS: Parents included in the investigation were 18 years of age or older with a medically stable preterm infant who was less than 36 weeks’ gestational age at birth, free of congenital malformations, and feeding orally. DESIGN: This investigation used phenomenology to explore the depth and richness of parental experience with the process of learning to feed orally their preterm infant. METHODS: Participants were recruited from a university-affiliated women’s hospital with a level III NICU. Purposive sampling was used to ensure that all participants were familiar with the experience of interest. Data collection consisted of personal interviews, which were conducted in a private consultation room located within the NICU. In instances where both the infant’s mother and father chose to participate, the interviews were conducted separately on the same day. MAIN OUTCOME MEASURES: Twelve mothers and 8 fathers participated in semistructured interviews. For 8 mothers and 6 fathers, this was their first child. This was the first preterm infant for all participants. From the parental experience, the following 3 themes were identified: an emotional experience, learn as you go, and it is technical. PRINCIPAL RESULTS: Parents noted that feeding encompassed both positive and negative emotions, that learning was a process that nurses played an instrumental role in, and that feeding a preterm infant could be very technical, requiring extra skills for feeding success. CONCLUSIONS: Nurses can play a key role in helping parents learn by acknowledging both positive and negative feelings about the feeding process, recognizing parents’ learning needs, and by teaching and demonstrating appropriate feeding techniques. Key Words: feeding, learning, parental experience, preterm infant
Author Affiliations: Nursing Program, Chatham University, Pittsburgh, Pennsylvania (Dr Stevens); School of Nursing, University of North Carolina, Wilmington (Dr Gazza); and Nursing Science, Cincinnati Children’s Hospital Medical Center, Ohio (Dr Pickler).
The authors declare no conflict of interest.
This study was supported by the University of Pittsburgh School of Nursing, T32 NR009759, Targeted Research and Academic Training Program for Nurses in Genomics. Dr Emily E. Stevens was a postdoctoral student and the only author supported by this training grant at the time of the investigation.
Copyright © 2014 by The National Association of Neonatal Nurses
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Correspondence: Emily E. Stevens, PhD, RN, WHNP, FNP-BC, Nursing, Chatham University, 222 Coolidge Hall, Woodland Rd, Pittsburgh, PA 15232 (estevens1@ chatham.edu).
DOI: 10.1097/ANC.0000000000000105 Advances in Neonatal Care • Vol. 14, No. 5 • pp. 354-361
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uccessful oral feeding is essential for a preterm infant’s discharge home. Although extensive research has been conducted on preterm infant oral feeding, few investigations have examined parents’ experiences learning to feed orally their preterm infant while in the neonatal intensive care unit (NICU). As such, the aim of this study was to explore parental learning experiences with the intent to improve preterm infant feeding outcomes by gaining a better understanding of the process parents use in learning to feed their preterm infant.
BACKGROUND AND SIGNIFICANCE To sustain life, grow, and be discharged from the hospital, an infant must be adequately nourished, a state that is dependent on the ability to ingest oral nutrition.1,2 For the preterm infant, the neuromuscular and gastrointestinal systems have not attained a level of maturity that allows for oral feeding. One of the most difficult challenges facing the preterm infant is the ability to feed orally, a challenge that is complicated by the lack of clear criteria of oral feeding readiness.3 The recognition of feeding readiness is often subjective. Although many investigators are grappling with developing objective measures of feeding readiness, to date no such measure exists.4,5 Moreover, although there is some research on “cue-based” oral feeding,6 cue-based oral feeding protocols have not been thoroughly investigated for their precision. In particular, these protocols have not been tested with mothers of preterm infants who must also develop skills at assessing readiness and then feeding the infant.7 There is a level of skill required to recognize signs of readiness for feeding, responsiveness to feeding, and signs of distress during feeding.8 Parents are encouraged to participate in oral feedings of their infants, even though most of them are not knowledgeable about preterm care in general and about determining preterm infant feeding readiness or tolerance of oral feeding. Researchers have investigated maternal and parental needs when feeding their infant in the NICU or after discharge. These investigations focused on the mother’s perspective for feeding success,7,9,10 maternal confidence in relation to preterm infant feeding experiences in the NICU,11 challenges encountered by the mother while feeding their preterm infant,12 experiences with feeding before and after discharge,13,14 specific needs of parents feeding a preterm infant with bronchopulmonary dysplasia after discharge home,15 and parental experiences with infant feeding difficulties.16 Although research about assessment of feeding skills and parent perspective or needs is important, researchers have not focused on understanding parents’ learning needs related to how to feed their preterm infant so that they are comfortable and confident in their skills,
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thus ensuring continued feeding success on their infant’s discharge. For the parent who is eager to provide direct care and nurturing to his or her infant, feeding is an especially important caregiving activity. New parents are often ill-prepared to initiate feeding of a full-term infant; feeding a preterm infant is even more complex and nuanced. To the preterm infant, feeding orally is an exhausting and potentially risky exercise. The preterm infant’s fragile and immature systems need every calorie and nutrient put toward growth and repair of damage created from existing outside of a protective womb. Therefore, any excess energy expenditure with oral feeding can actually be detrimental to overall health.17 Without proper knowledge and technique of how to feed a preterm infant, excessive caloric expenditure and physical exhaustion may occur. As a result, the preterm infant may suffer from poor weight gain, delayed oral feeding development, and physiological decompensation as evidenced by apnea, bradycardia, oxygen desaturation, and aspiration.18 Despite the negative consequences associated with inadequate nutritional intake and feeding difficulties, little is known about how to best teach parents to feed their preterm infant.7 The process of promoting parental comfort and achieving successful feeding outcomes remains unclear. A better understanding of the dynamics and interactions between parents and healthcare providers surrounding the process of learning to feed preterm infants in the NICU may improve preterm infant feeding outcomes during hospital stay and after discharge. Thus, the purpose of this study was to describe parents’ experiences when learning to feed their preterm infant.
METHODS Design The qualitative method of phenomenology was chosen for this study because its purpose was to focus entirely on the depth and richness of participant description and interpretation of their lived experiences. This personal explanation from each participant is necessary to capture the phenomenon of interest.19 Setting A university-affiliated women’s hospital with a level III NICU was used for this investigation. This NICU has a total of 77 beds and cares for more than 1800 preterm infants every year. As such, it is staffed by highly trained neonatologists, nurse practitioners, and nurses. Sample To be included in the study, the parent had to be 18 years of age or older with a medically stable preterm infant who was less than 36 weeks gestational age at
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birth, without congenital malformations, and bottlefeeding orally. For the purpose of this investigation, medically stable was defined as the absence of mechanical ventilatory assistance, total parental nutrition intravenous feedings, intravenous fluids, and intravenous and/or oral medications. Supplemental oxygen via nasal cannula, oral vitamin supplements, and nasogastric feedings were permitted. Parents of twins were also included because they were having the experience of interest—learning to feed a preterm infant. However, parents who were breastfeeding were excluded because the skills required and experiences may differ significantly from those associated with bottle feeding.
Procedures Before beginning the investigation, institutional review board approval was obtained. All participants signed a written informed consent before data collection. Participants were recruited from a university-affiliated women’s hospital with a level III NICU. All nurses in this NICU are trained on the same feeding protocol annually and use this protocol when educating parents on feeding their preterm infant. Purposive sampling was used to ensure that all participants were familiar with the experience of interest. Data collection consisted of personal interviews conducted in a private consultation room. In instances where both the infant’s mother and father chose to participate, the interviews were conducted separately on the same day. At the end of each interview, the investigator asked demographic questions, including age, the number of children, educational level, and household income. All interviews were conducted from January through May 2010. To establish scientific rigor and trustworthiness of the investigation, all interviews were conducted by 1 researcher and transcribed by a transcriptionist trained in qualitative research. Length of interviews ranged from 4 to 12 minutes. Semistructured interviews were used for data collection. The interviews began with a general question about the parent’s experiences in feeding his or her infant for the first time, allowing parents to determine the direction of the discussion. Parents were then asked to describe their experiences in learning to feed their infants including any “education” or support provided by the NICU staff. Parents were asked to reflect on experiences that influenced their own skill development and areas where they felt that further knowledge and skill were needed. Several questions guided the interview (Table 1). However, this list was not inclusive and all of these questions were not asked of every participant. To ensure that the phenomenon investigated was described adequately for the researcher’s interpretation, additional questions that arose were pursued for clarification as the interview progressed. Time
TABLE 1. Interview Questions Tell me what it was like when you fed your baby for the first time. Tell me about your experiences when learning how to feed your infant. Tell me about any education you received on how to feed your son or daughter. Tell me about any support, which helped or hindered you when learning to feed your son or daughter. Describe any experiences with the NICU health care providers that significantly impacted your learning. What do you think influenced how you feed your baby. What do you think you need to know to take over feeding your baby at home? Abbreviation: NICU, neonatal intensive care unit.
limits were not imposed on the interviews. Interview length was determined by the participants, noting that they had nothing left to say about their preterm infant feeding experience. The interviews were audiotaped and transcribed precisely by a trained transcriptionist.
Data Analysis The goal of data analysis was to identify common themes and language that captures the theme. The same data analysis process was consistently used throughout the study by the 2 investigators who conducted data analysis to establish trustworthiness of the results. Each investigator completed an independent analysis of the data. Findings were then compared, and minor variations were discussed and resolved after interview data were reevaluated. The transcribed narrative was read, and important elements were identified by underlining or highlighting language used by the participant. These important elements were those that formed the meaning of the parents’ experiences. Tentative theme names or codes were assigned to these experiences. Once a narrative was analyzed, it was compared and contrasted with narratives of other participants. The purpose of this step was to identify common themes across all narratives that reflect the experience of all participants. Exemplars were identified for each theme, which are portions of textual data that captured the essential meaning of a particular theme or code19 to describe the phenomenon of parents learning to feed their preterm infants. The exemplars were compared and agreed on among the investigators before drawing final conclusions.20 www.advancesinneonatalcare.org
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RESULTS Demographics Twenty parents consented to participate in the study. After all 20 interviews were completed, it was felt that no further recruitment was needed because of similarities in the data. The final sample consisted of 12 mothers and 8 fathers. Of those parents interviewed, 8 were couples. For 8 mothers and 6 fathers, this was their first child. Furthermore, this was the first preterm infant for all participants. Additional participant demographic information is provided in Table 2. The preterm infants of the participants consisted of 8 males and 6 females. The infants’ gestational age at birth ranged from 26 to 35.6 weeks (M = 32.9 weeks). The average birth weight was 1936.2 g with a minimum weight of 748 g and a maximum weight of 2635 g. None of the preterm infants had craniofacial malformations or an intraventricular hemorrhage grade III or IV, and all were bottlefeeding.
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TABLE 2. Parental Demographicsa Characteristics
n = 20 (%)
Gender Male Female
8 (40) 12 (60)
Race African American White
4 (20) 16 (80)
Parental age, y 18-25
5 (25)
26-30
9 (45)
31-35
1 (5)
36-40
3 (15)
40-45
0 (0)
46-50
2 (10)
Number of living children
Themes The data analysis revealed the following 3 themes: (1) an emotional experience, (2) learn as you go, and (3) it is technical. To protect participants’ identities, pseudonyms are used when reporting the results. Theme 1: An Emotional Experience All participants spoke about the emotional aspect of orally feeding their preterm infant in the NICU (Figure). “Feeding” encompassed more than providing nourishment needed for growth. It was an emotional experience that included feeding and being able to touch and hold their infant, look closely at the infant, and interact and “bond” with the infant. Frank’s description exemplifies that the experience was more than providing nourishment to his second child. He stated, “(The) very first time (feeding the baby) was just great, to tell you the truth. It was an experience, just like, ‘Wow’ … it was just looking into him and just like, ‘wow, look what we made, y’know?’ It was just crazy … it was just wonderful.” Another father, Jonas, had a similar experience in terms of relating to his infant daughter. He stated, “It was pretty awesome [laughing] because (his daughter) had been in an incubator for a while and we couldn’t hold her and then we actually got to hold her. Holding a baby is something that I’ve always wanted so to me it was priceless. … I was a little nervous about patting her on the back and burping her and stuff.” There was no predominate emotion associated with the oral feeding experience. Instead, the participants spoke of a wide range of emotions, from positive to negative that were associated with feeding their preterm infant in the NICU. Janelle explained the positive feelings that she experienced when able to feed her daughter. She stated, “It felt good because it was like 3 days after I had her before
1
13 (65)
2
3 (15)
3
0 (0)
4
1 (5)
5
3 (15)
Highest level of education High school
3 (15)
Certificate program
2 (10)
Some college
6 (30)
Undergraduate degree
6 (30)
Graduate degree
3 (15)
Household income ($) 100,000
1 (5) 4 (20)
Two participants chose not to provide information on their household income. a
I even got to do it I was pretty excited about it, to do it. She wasn’t allowed out of the incubator so I had to do it with my hands through (the incubator portholes) but I was just happy to get to feed her.” Both June and Maria expressed negative feelings when feeding their baby. Maria described her feelings as “… kind of overwhelming for the minute, because you’re just trying to take it all in, realize
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FIGURE.
Mother feeding her preterm infant.
that, ‘Okay, he is okay’. Feeding him went really well … I was just nervous he was going to choke on it or something.” June stated, “(I felt) a little nervous because he was so little, if he was going to take it all, and those alarms went off a little bit because he was sucking in too much air, so that scared me.” In all, there were more negative than positive emotions expressed with 12 participants, stating that they felt nervous, anxious, or apprehensive, and a few noting that it was “scary” to feed their baby the first time. Theme 2: Learn As You Go Learning to feed a preterm infant was an individualized process for each participant that took place over variable lengths of time and through the use of various approaches. In some cases, learning needs were minimal and were met in a short period of time. For other participants, their needs were more complex. Maria’s statement best exemplifies the individualized learning process that occurs over time. She stated, “I guess you kinda have to learn as you go [emphasis added].” For some participants, this learning process may not be fully complete before discharge. Many participants were uncertain about various aspects of feeding and had unanswered questions. This was exemplified best by Brandon, who said, “I know they said like every 3 hours but like after that when do you progress onto something else? Is there bottles that tell you ages of sizes or—I don’t honestly know.” Although others felt secure about their feeding knowledge and ready to take their infant home, like Emma, who stated, “There’s not much that I think I need to learn.” Learning occurred through various formal and informal activities, with the most common being learning from the nurses. Participants described how they received verbal instructions from nurses about
how to feed their infant, observed nurses feeding their infant, were observed by a nurse as they fed their infant, used trial and error, and practiced feeding their infant to learn how to feed their preterm infant. Sam described various techniques that he used to learn how to feed his preterm twins. He stated, “I was kind of watching the nurses and the nurses were good about showing me what to do. … Some would kind of watch from afar and some would stay there a little closer … but if I was struggling with it they would usually come in and say something. … [They gave] little pointers and tips about what to do and when to burp him and what to look for in terms of their behavior.” In addition, Mark explained, “There’s a couple of nurses that were real helpful. They (the nurses) picked her up and held her and just started feeding her and said, ‘This is how you do this.’ After observing the nurses, the parents fed the infants and the nurses watched them for “awhile until they knew we had it.” Mark’s significant other, Cynthia, described her approach to learning to feed their daughter. She said, “Trial and error, just being here for every feeding that I could … just working with her and figuring out just by feeding her what she likes and what works and what doesn’t.” Theme 3: It Is Technical All of the participants focused on the technical aspects of feeding their preterm infant. Mark stated, “We just assume that it was just like a regular baby … we didn’t realize how technical it was to feed a premie [emphasis added], to keep her head back and all that.” As such, the participants used various techniques to try and safely feed their preterm infants and promote weight gain and growth. Thomas stated, “If one (technique) doesn’t work I kind of move to the next one. … I kind of use a combination of everything now to get him to keep on a rhythm.” Techniques ranged from how to hold the infant and bottle, how to coax the infant to eat more, what to do if the infant fell asleep during feeding, and how to manage the entire feeding process once they were at home. Danielle, the mother of premature twins, explained, “… with the bottle fed baby, you kind of have to hold them a little bit away so they stay awake because it’s just a different positioning and you want to make sure that they’re taking the full volume. In a NICU, they measure everything so you want to be sure that they take everything so that they’re gaining weight adequately and keeping them awake long enough by holding them out. …” Christina also shared quite a few techniques that she used. “I’ll kind of like tickle under chin like I’ll put my finger under there and rub or try to massage his cheeks a little bit. And if I twist the bottle sometimes around that’ll get him to eat or kind of like move the nipple and under his chin at the same time like www.advancesinneonatalcare.org
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making the motion of the sucking sometimes that gets him to start sucking.” Participants were also attentive to multiple factors during the feeding. For instance, Maria described all of the factors that she was attentive to during the feeding process including bradycardia, the infant’s appetite and body temperature, and the use of the feeding tube when oral intake was inadequate. She stated, “He (the infant) might have to go home with a monitor (for bradycardia) … I have to take a class for that to learn how to deal with all of that. … I do get flustered when he won’t eat and it has to go through the tube cause I still have to think, ‘okay, the bili lights been off for 2 days, why isn’t his appetite coming back?’ … Now they are weaning him out of his bed … like how much energy he’s using to keep warm. I just constantly feel like, ‘Are we regressing? Are we moving forward? It’s really hard to wrap your head around it [everything she has to pay attention to when feeding the infant].” Greg’s experience also exemplifies being attentive to multiple variables. He stated, “I had to learn certain things like to make sure his tongue is under the nipple and things like that. … I was getting thrown up on a lot and spit up on a lot at first but I’m kind of catching the signs of when he needs a break and when he needs a burp. … If milk starts coming out of his mouth just a little bit like he’s not swallowing all the way, I’ll usually give him a break and burp him … not forcing him.”
DISCUSSION Findings indicate that it was an emotional experience for parents to feed orally their preterm infant for the first time. This emotional experience varied significantly among participants encompassing both positive and negative feelings. However, the majority of participants expressed a negative emotion when beginning the process of learning to feed their preterm infant. Touching the preterm infant was also a contributing factor to the emotions experienced with feeding because, for some parents, the first feeding might have been the first time they held their infant in their arms. Interestingly, these results are similar to a systematic review by Jambulingam,21 who critically examined maternal anxiety in the NICU. Although the review was not focused specifically on feeding in the NICU, mothers’ NICU experiences were described as were nursing interventions to alleviate anxiety. The results indicated that mothers noted many negative emotions including anxiety and that nurses used maternal touching of the infant to alleviate this anxiety.21 In this investigation, parents did not make the connection between alleviation of negative emotions and touching their preterm infant. Coupled with Jabulingam’s findings, one might speculate that there may be an underlying
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association between touch and emotional response for parents related to infant feeding. There was also a learning process involved with feeding, and parents varied considerably in their learning needs. Some parents seemed secure and ready to take responsibility for feeding their infant at home, whereas others were unsure of what to expect and were still seeking answers to questions. These findings are consistent with the findings of other researchers14 who have noted that parents tend to struggle with infant feeding in the first few weeks after discharge and experience a period of transition before comfort develops. Opportunities for learning and instruction also differed among participants with the nurse playing a central role. Parents in this study emphasized the importance of the NICU nurse, teaching them how to feed their preterm infant. This too is not a novel finding, but it does confirm both the findings and recommendations found in previous investigations7,9,11,22 and suggest the need for feeding guidelines.2,23,24 Moreover, this finding further documents the importance of nurses in assisting parents as they learn to safely feeding their preterm infant. In addition, as suggested in previous investigations, feeding a preterm infant was very technical for parents and involved skills specific to meet their infants’ feeding needs.7,14 This encompasses the parents being aware of environmental factors around them, such as medical equipment, and monitors as well as developing understanding about their preterm infant’s physiological responses. These findings suggest the need for nurses to create situations for parents in which they learn to identify infant feeding cues and develop skills in various techniques used to promote infant feeding. Although oral support is effective for improving preterm infant feeding performance,25 some of the techniques that parents described using are not supported in the literature as safe or efficacious. These descriptions stand as a reminder that parents watch caregiver behaviors and emulate them without the ability to judge appropriateness. The literature contains few articles that detail or focus on parental experiences feeding their preterm infant in the NICU and the learning process involved. Although the interview lengths were determined by participant sharing and were brief, the experiences were overwhelmingly similar. As such, the participant accounts presented here reveal parents’ experiences of what it was like to learn how to feed orally their preterm infant. These results are not generalizable to other populations given the nature and design of this study. Recommendations and clinical implications from this investigation to assist parents learning to feed their preterm infant are provided in Table 3.
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TABLE 3. Recommendations Recommendation/Clinical Implication
Theme An emotional experience
Provide opportunities for skinto-skin care and therapeutic touching of the preterm infant before and during feeding (especially when in an incubator) Acknowledge parental feelings about feeding such as being anxious, discouraged, scared, uncomfortable, and nervous or excited
Learn as you go
Nurses need to be aware of the evidence base for the techniques that they use to improve oral feeding behaviors Nurses should be cognizant that many parents watch them and model their feeding techniques Evaluate where parents are in the learning process and provide time for further feeding education to meet their skill needs Provide resources or contacts to answer feeding questions after the infant is discharged
It is technical
Educate parents on the physiological differences associated with prematurity and the physical demands of oral feeding that result in a need to use different feeding techniques Provide educational materials with research about oral feeding Record a demonstration of appropriate “cue-based” feeding techniques
CONCLUSIONS Although this investigation provided valuable insight to parental learning experiences while feeding their preterm infant, it also revealed the need for further investigation of the nurses’ knowledge in relation to feeding and psychosocial skills, parental teaching methods, and preterm infant feeding
techniques. Perhaps, it would be advantageous to explore the type of education and knowledge of nurses in the NICU about effective or safe preterm infant feeding techniques. Additional studies might focus on NICU nurse orientation and training methods around infant feeding and parent teaching. For instance, how are nurses being taught to read the preterm infant feeding cues? What types of cues are they being taught? And, what types of techniques are being taught in response to these cues? Having NICU nurses who can articulate and demonstrate feeding a preterm infant is vital to assist parents with their learning process. Nurses who are sensitive toward parents’ emotions may also be beneficial with the learning process. Evaluation of nurse needs for and development of psychosocial skills may be another area that would benefit from investigation. Further attention on best strategies for teaching parents about preterm infant feeding, particularly focusing on the infant’s developing capabilities, could also be helpful. Finally, further research about techniques used to feed preterm infant is essential to ensure that evidence-based feeding methods are implemented in the NICU as well as when the preterm infant is discharged home.
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Parental Preterm Infant Feeding Experience 16. Swift M, Scholten I. Not feeding, not coming home: parental experiences of infant feeding difficulties and family relationships in a neonatal unit. J Clin Nurs. 2009;19:249-258. 17. Pridham K, Bhattacharya A, Thoyre S, et al. Exploration of the contribution of biobehavioral variables to the energy expenditure of preterm infants. Biol Res Nurs. 2005;6(3):216-229. 18. Mason SJ, Harris G, Blissett J. Tube feeding in infancy: implications for the development of normal eating and drinking skills. Dysphagia. 2005;20(1):46-61. 19. Cohen MZ. Hermeneutic Phenomenological Research: A Practical Guide for Nurse Researchers. Thousand Oaks, CA: Sage; 2000. 20. Streubert H, Carpenter D, eds. Qualitative Research in Nursing: Advancing the Humanistic Imperative. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
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21. Jambulingam M. Anxiety in mothers with preterm infants in the neonatal intensive care unit. J Obstet Gynecol Neonatal Nurs. 2012;41(suppl 1):S152. 22. Pridham K, Schroeder M, Brown R. The adaptiveness of mothers’ working models of caregiving through the first year: infant and mother contributions. Res Nurs Health. 1999;22(6):471-485. 23. Thomas JA. Guidelines for bottle feeding your premature baby. Adv Neonatal Care. 2007;7(6):311-318. 24. Thoyre S. Techniques for feeding preterm infants: education calms parents’ fears regarding proper care. Am J Nurs. 2003;103(9):69, 71,73. 25. Hwang YS, Lin CH, Coster WJ, Bigsby R, Vergara E. Effectiveness of cheek and jaw support to improve feeding performance of preterm infants. Am J Occup Ther. 2010;64(6):886-894.
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